Medicare AdvantageDocumentationMedium impact
MA08.137d, Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®)
Independence Blue Cross·Psychiatry, Pain Management, Anesthesiology·Pharmacy
Effective date
Dec 29, 2025
We identified it
Jun 19, 2026
Summary
MA08.137d updates medical necessity criteria for intravenous ketamine (Ketalar®) and intranasal esketamine (Spravato®). This is a recent policy change (1 month old) affecting Medicare Advantage plan coverage and billing requirements for these medications. The billing team must review the specific medical necessity criteria and ensure claims align with updated guidelines.
Action Required
By 2025-12-29: Billing team must obtain and review the full MA08.137d policy text from the source URL to identify specific medical necessity criteria, prior authorization requirements, and any billing code restrictions for intravenous ketamine and intranasal esketamine. Update claim submission procedures and provider documentation templates to reflect new criteria. Coordinate with providers to ensure prescriptions and clinical documentation meet the updated medical necessity standards. Flag any claims submitted before policy review for potential reprocessing. Failure to implement these criteria may result in claim denials on Medicare Advantage plans.